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Essay On Life Support

Basic Life Support or BLS is that level of medical care for those in a life-threatening situation until the arrival of proper medical care. BLS can be provided either by emergency medical personnel, trained medical professionals or by laymen trained in BLS. The techniques in BLS are mainly focused on airway maintenance, breathing and circulation. Use of automated external fibrillator or AED for defibrillation is a recent advance in BLS and has resulted in improved cardiac survival in cardiac arrest cases.

This new intervention is important because majority of the deaths in cardiac arrest cases are due to ventricular fibrillation which can be reverted using a defibrillator in the electrical phase of ventricular fibrillation. Thus, basic life support consists of chest compressions and ventilations and also early defibrillation. Advanced Life Support or ALS is that form of medical care prior to reaching hospital and which can be delivered only by trained medical personnel or paramedics.

This form of medical care involves many invasive and non-invasive procedures like transcutaneous pacing, intravenous cannulation, cardiac monitoring cardiac defibrillation, intraosseous infusion, needle or surgical cricothyrotomy, , advanced medications through enteral and parenteral routes and endotracheal intubation. Whether BLS or ALS is critical in improving outcomes in cardiac patients is a much debated topic.

According to a multicentric controlled study conducted by Stiell et al (2004) on the benefits of advanced life support in out-of-hospital cardiac arrest patients, advanced life support interventions did not have any added advantage over basic life support. The study revealed that when compared to BLS with rapid defibrillation programs, ALS programs did not have any added benefits. The authors recommended that cardiopulmonary resuscitation by bystanders and rapid-defibrillation responses must be encouraged and should be a priority for EMS resources.

The study concluded that though advanced life support increased the rate of admission to hospital significantly; the rate of survival did not improve, placing more importance on basic life support. In a recent study by Markel et al (2009), the authors aimed to study the outcomes in cardiac arrest patients after they were delivered with basic life support and advanced life support. Their study revealed that BLS-to-ALS survival was an important predictor of survival to hospital discharge.

Every minute of decrease in the arrival of ALS following delivery of BLS was associated with 4% decrease in survival chances. The authors concluded that shorter BLS-to-ALS time is associated with increased survival chances and hence ALS interventions must be utilized for additional benefits. However, the researchers pressed the need for early CPR and defibrillation which is BLS. Different reports were produced by an old study by Bissell et al (1998). This study reviewed extensive literature pertaining to delivery of ALS and BLS to cardiac arrest patients.

Of the 51 articles reviewed, eight articles reported that ALS was in no way better than BLS; seven reported that ALS was effective in some application and the remaining articles concluded that ALS was superior to BLS. The researchers concluded that ALS may be clinically superior to BLS in some patients with certain pathologies. Despite different clinical opinions, it can be said that BLS plays a critical role in the survival chances of a cardiac arrest patient. There are 2 reasons for such an impression. 1. Any bystander can provide BLS if he or she has received some amount of training in BLS.

2. Most of the cardiac arrest cases are due to ventricular fibrillation and defibrillation is “the treatment” for that condition Current studies being conducted into new methods, drugs and/or equipment being studied to improve cardiac survival. Over the past few decades, many new methods, drugs and interventions have been introduced to provide optimum support for patients with cardiac arrest so that the chances of survival are enhanced. Every year, newer approaches are coming up to provide the best possible care for cardiac patients.

This article explores the recent trends in cardiopulmonary resuscitation of cardiac patients in a prehospital setting. Latest international guidelines for cardiopulmonary resuscitation have stressed the need uninterrupted cardiopulmonary resuscitation or CPR so that there is continuous delivery of adequate coronary artery perfusion pressure which is one of the key determinants for return of spontaneous circulation. To facilitate uninterrupted CPR, a new concept of “hands on” defibrillation has been developed.

Research has shown that when CPR is continued with gloved hands during defibrillation, there is absent or minimal shock to the resuscitator (Roppolo et al, 2009). According to the American Heart Association (2005), in children, the chest compressions must be provided at the rate of 100 per minute without any interruption for respiration. According to a study by Bobrow et al (2008), implementation of minimally interrupted cardiac resuscitation increases the survival-to-hospital discharge in those who suffered cardiac arrest out of the hospital.

A recent research proved that ‘noise reduction’ automated external defibrillator and cardiac monitoring analysis can allow certain advanced devices to distinguish a CPR infarct from V-fib (Roppolo et al, 2009). Another new approach aimed at cardiac survival is the cardiocerebral resuscitation or CCR. This method is mainly composed of 3 aspects: continuous chest compression by bystander, new EMS algorithm and vigorous post-resuscitation care. There is no mouth-to-mouth breathing in this approach.

The approach also favours defibrillation, either in the early or late stages (Ewy and Kern, 2009). Recently an automated, load-distributing band chest compression device has been introduced for cardiac resuscitation in a prehospital setting. Ong et al (2006) compared the outcomes of resuscitation between manual and automated cardiac resuscitation. Their study concluded that automated cardiac resuscitation use by EMS is associated with better outcomes. The previous decade has seen much research in the combined use of active compression decompression CPR and impedance threshold device.

Frascone et al (2004) reviewed literature pertaining to this emerging therapy. The authors concluded that use of this new technology should be encouraged as this combination therapy provided optimum vital organ blood flow. References American Heart Association. (2005). 2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) of pediatric and neonatal patients: pediatric basic life support.

Pediatrics, 117(5), e989-1004. Bobrow, B. J. , Clark, L. L. , and Ewy, G. A. (2008). Minimally interrupted cardiac resuscitation by emergency medical services for out-of-hospital cardiac arrest. JAMA, 299(10), 1158-65. Bissell, R. A. , Eslinger, D. G. , and Zimmerman, L. (1998). The Efficacy of Advanced Life Support: A Review of the Literature. Prehospital and Disaster Medicine, 13(1), 69- 79. Ewy, G. A. , and Kern, K. B. (2009). Recent advances in cardiopulmonary resuscitation: cardiocerebral resuscitation. J Am Coll Cardiol. , 53(2), 149-57. Frascone RJ, Bitz D, Lurie K. (2004).

Combination of active compression decompression cardiopulmonary resuscitation and the inspiratory impedance threshold device: state of the art. Curr Opin Crit Care, 10(3), 193-201. Markel, D. T. , Gold, L. S. , Farenbuch, C. E. , and Eisenberg, M. S. (2009). Prompt Advanced Life Support Improves Survival from Ventricular Fibrillation. Prehospital Emergency care, 13(3), 329- 334. Ong, M. E. , Ornato, J. P. , Edwards, D. P. (2006). Use of an automated, load-distributing band chest compression device for out-of-hospital cardiac arrest resuscitation.

JAMA, 295(22), 2629-37. Roppolo, L. P. , Wigginton, J. G. , and Pepe, P. E. (2009). Minerva Anesthesiol, 75301-5. Stiell, I. G. , Wells, G. A. , and Field, B. (2004). Advanced Cardiac Life Support in Out-of-Hospital Cardiac Arrest. The New England Journal of Medicine, 351, 647- 656. Appendix Please download articles from these links provided: http://www. ncbi. nlm. nih. gov/pubmed/16651298? ordinalpos=1&itool=EntrezSystem2. PEntrez. Pubmed. Pubmed_ResultsPanel. Pubmed_DiscoveryPanel. Pubmed_Discovery_RA&linkpos=5&log$=relatedarticles&logdbfrom=pubmed



    When a patient is being maintained by life-supports,
we are often faced with the decision about when to end such supports.
And it is now becoming more common to 'pull the plug'
before the patient dies despite the 'tubes and machines'.

    We do have informal and behind-the-scenes methods
for making such withdrawal decisions.
If we were to regularize and formalize these life-ending decisions, 
perhaps some of the same safeguards for 'pulling the plug'
could be applied to other decisions about drawing life to a close,
even for patients who are not dependent on life-supports.







    If we become more comfortable with the thought of
turning off the tubes and machines that keep patients alive,
perhaps this will enable us to think more deeply
about the process of making medical decisions
in other situations in which medical technology
is not a major factor.


by James Leonard Park

    As the 21st century advances,
more of us might be supported by machinery and drugs
in the last few days or weeks of our lives.
If we die from some disease or condition
that normally takes months or years to bring death,
then our dependence on life-support systems might be even longer.

    If we are being kept alive by some form of medical technology,
then any decisions we make about the
best time to die
and about the
best means to allow our deaths
will have to include questions about
what to do
with the life-support systems in place—keeping us alive.


    Medical ethics in the 21st century includes discontinuing life-supports.
And some end-of-life decisions include never starting life-supports
when it is clear in advance that putting us on a ventilator, for example,
will only prolong the process of dying.
If there are no particular reasons to keep us alive for a few more days,
then everyone involved in this end-of-life decision
will probably agree not to extend the process of dying.
And even when there is no clear decline into death
because further deterioration is being prevented by the life-supports,
reasonable people can agree that if there will be no recovery,
there is no point in keeping us in a coma on life-supports indefinitely.

    On the other hand, when we are drawing our lives to a close,
we might have some very meaningful things we want to achieve
before the end of our lives.
And usually these will be quite independent
of any objective facts found in our medical charts.

    For example, we might have some religious practices or good-byes
that we want to complete before we 'allow nature to take its course'.
We might want to have our sins forgiven before we 'meet our Maker'.
We might want to make amends with estranged family members.
We might want to see a grandchild or great-grandchild before we die.

    If we imagine our lives as a movie or play,
we know what scenes we would like to have before the end of the show.
And if we are realistic about the amount of time left,
we will know which projects we can complete within that time-span
and what new projects would be unrealistic.


    'Pulling the plug' on our life-support systems carries no stigma,
as might be the case with taking a lethal chemical to bring death.
Perhaps this is because we can see clearly (and sometimes dramatically)
that 'life' in the intensive care unit (ICU)   
has almost no similarities to the life we lived
in all the years leading up to this final scene.
When we are being supported by a heart-lung machine
that is keeping our blood circulating and oxygenated,
we know that this situation cannot continue indefinitely.

    Our feelings about 'pulling the plug' are somewhat different
when the life-supports seem more like daily living.
For example, our lives might be sustained
by medication to control our blood-pressure
to keep our hearts and blood vessels operating well.
If we
go off that medication, we know that we could easily die
from the cardio-vascular problem now controlled by the drugs.

    At least in the advanced parts of the world, if we live long enough,
most of us will be using various medications at the end of our lives.
And we might have
so manydifferent prescription drugs
in our bodies that we cannot remember them all.
We might have experienced continual adjustments of our drugs
because of the subtle interactions among them:
One drug causes a particular side-effect,
which needs to be controlled by another drug, etc.

    In such situations, when we are ready for our lives to end,
we can simply refuse to take
anyof the drugs that are keeping us alive.
Our doctors can tell us how long we can expect to live
without the medications that have been assisting our vital functions.

    A somewhat more controversial situation arises
when the life-support is a
or other means of supplying food and water.
At the end of our lives, if we cannot eat normally,
then we might be attached (either temporarily or permanently)
to a feeding-tube that puts special foods directly into our
Or we might have fluid and nutrition put directly into our
—by-passing our digestive systems completely.

    But even discontinuing artificial feeding
has now become a part of standard medical practice.
Such decisions should not be taken lightly
and without considering all the implications for everyone involved.
But from the perspective of medical practice
discontinuing artificial nutrition and hydration
is a common method of managing dying.

    When we think of our own lives coming to an end
by means of withdrawing or withholding a feeding-tube,
we know that the utmost caution is needed
in the decision-making process that might lead to this action.
Each of us should consider just how such a life-ending decision
should be reached with respect to our own lives.
And we should explain our plans in our Advance Directives for Medical Care.
If we clarify our own medical ethics well in advance of any situation
in which withdrawing a feeding-tube becomes a real option,
we have considered this method of managing dying,
probably years before it becomes a real-life choice.


    It probably does not happen very often in medical institutions,
but sometimes
harmfuldecisions are made
with inadequate consideration of all the options.
should be protected from possible mistakes and abuses
of any protocol that allows withdrawal of life-support systems.

    Our doctors will provide the medical facts and recommendations.
And because one doctor might miss something important,
other doctors—perhaps specialists in our disease or condition—

might be called upon to examine us and to explore our medical options.

Our own views on life and deathshould shape our end-of-life choices.
Each of us has strong beliefs and values
that we have been using to shape our lives thru-out adulthood.
We have some life-principles that form the basis of our medical ethics.
And here also, it might be useful to ask for input from others.
There might be people we trust who will help us to formulate
our own values concerning life and death.

    And even beyond helping us to clarify our own values,
the views of others who have been close to us
might have to be called into action
if and when we can no longer make our own medical decisions.
This is the role of
medical proxies,
whom we should appoint in our Advance Directives for Medical Care.
When we are beyond making our own choices,
our proxies are empowered to make all of the medical decisions
that were automatically given to us while we were still full persons.

    If we find ourselves in difficult dilemmas at the end of our lives,
we might have occasion to call upon a group of ethical consultants.
There might be an institutional ethics committee
in the hospital or nursing home that is providing our terminal care.
Because these people have faced similar situations,
they might be able to offer wise advice to the official deciders
—ourselves as the patient and/or our appointed proxies—

who might be facing life-ending decisions for the very first time.

    Another layer of protection would be the
legal system.
We have laws and the means of enforcing them
so that people who cannot always protect themselves
will be saved from others who might have harmful aims.

    The same safeguards that we apply to withdrawing life-supports
could also be applied to other forms of life-ending decisions.
Even if we are
notconnected to tubes and machines at the end of our lives,
we still do have the right to choose
best timeand the best meansfor our lives to end.

    We should decide our own lives and deaths,
possibly getting feedback from the people closest to us.
We should appoint proxies who will carry forward our settled values
if and when we can no longer decide for ourselves
or can no longer express our wishes.

    Whoever is called upon to offer an opinion or make a decision
should be sure to consider all the available alternatives.
And it might even be wise to put these deliberations into writing,
in case these decisions might need to be reviewed later
by others who were not present when the choices had to be made.
Some relatives might be quite distant
and be included in the decision-process only when the end is near.
So, instead of starting the process all over from scratch,
these late-comers can be permitted to read the death-planning record,
which details all of the deliberations to that point.

Ifthe practice of withdrawing life-supports
does indeed become the
paradigm for all life-ending decisions,
then we will discover some 'safeguards' that are really
not appropriate.
If any proposed safeguards have never been applied
to any situations of giving up life-support systems,
then they should not be applied to other circumstances.

    Here is an extreme example:
Some opponents of the right-to-die hold
that doctors should never cooperate in any death-planning process.
This sometimes takes the form of ethics affirmed by a medical society:
"Doctors must not kill."
But it would be very difficult to apply such a 'hands-off' policy
to life-ending decisions that include withdrawing life-supports.
If doctors can give their professional opinions concerning life-supports,
they should also be permitted to give the medical facts and opinions
that would be relevant to other kinds of life-ending decisions.

    Perhaps we need laws to regularize the withdrawal of life-supports.
And any such provisions could be included
in new laws against causing premature death.
Here is a model for such laws:
This draft legislation contains 26 safeguards for life-ending decisions.


    As more of us gain experience with terminating life-supports,
we will become more familiar with the safeguards that should be used
to make sure that any
harmto the patient is less than
harm already being inflicted by the life-support systems themselves.
Of all deaths that now occur in hospitals,
about 80% involve some important elements of choice.
If no choices are made, the patients will continue to be maintained
on life-support systems until they die
despitethe 'tubes and machines'.
How often are patients 'treated-to-death'?

    As a culture, we have not given much attention to life-ending decisions.
ifover half of deaths in America now include some choices,
we are already making over a million life-ending decisions each year.
Implicit safeguards are already being used for these medical decisions.
And as we become more aware of medical decisions that bring death,
we can make the safeguards
more explicit
—perhaps with an eye on other life-ending decisions
that are not so completely within the control of doctors.

    As we learn to make wise decisions about terminating life-supports,
we are also learning how to articulate the safeguards
that should be applied to
all life-ending decisions.
The right-to-die means being able to make wise decisions
so that we can die at the
best timeand by the best means.

    Pulling the plug is sometimes the wisest end-of-life medical choice.

Created February 2, 2007; revised 9-2-2007; 10-9-2007; 2-2-2008; 12-11-2008; 4-22-2009;
2-14-2010; 4-22-2010; 11-18-2010; 2-24-2011; 3-11-2011;
1-13-2012; 2-3-2012; 2-10-2012; 2-27-2012; 3-21-2012; 7-7-2012; 8-31-2012;
3-30-2013; 5-17-2013; 6-7-2013;
2-11-2015; 4-18-2015; 7-11-2015; 10-8-2015; 12-23-2015;
1-24-2016; 2-9-2016; 11-7-2017;

How has this chapter changed your mind?

Did you once think that 'pulling the plug' was not permitted?
Did you think that once life-supports were started,
it would be wrong to discontinue them?
If someone you love is ever on life-supports,
how would you decide to disconnect the tubes and machines?
If you yourself are ever kept alive by life-supports,
do you now think you could authorize your death by withdrawing them?

Safeguards Website:

    If you would like to explore
safeguards for life-ending decisions
here is an organized catalog of over 30 such proposed safeguards:

    And here is the selection of 26


    James Park is an independent thinker
with deep interest in medical ethics,
especially the many issues that arise at the end of life.  
Medical Ethics and Death are two of the ten sections of his website:
James Leonard Park—Free Library

    This essay about withdrawing life-supports
as a medical method of managing dying
has become a chapter in a small book entitled:
Right-to-Die Hospice


If you agree with disconnecting life-supports as a valid method of managing dying,
consider joining a Facebook Group and Seminar called Right-to-Die Hospice.

This discussion group is completely free of charge.
And members are welcome to join from anywhere.

The above discussion of disconnecting life-support systems
has become Chapter 7 of Right-to-Die Hospice.
Our Facebook Group of the same name will discuss one chapter per week.

Here is a complete description of this on-line gathering of advocates of the right-to-die:

And here is the direct link to our Facebook Group:
Right-to-Die Hospice:


The above exploration of terminating life-support systems

is also Chapter 48 of How to Die: Safeguards for Life-Ending Decisions:
"Pulling the Plug: A Paradigm for Life-Ending Decisions".

Would you like to join a world-wide Facebook Seminar
that is discussing this book-being-revised?

See the complete description for this first-readers book-club:

Join our Facebook Group called:
Safeguards for Life-Ending Decisions:

A few related essays:

A New Way to Secure the Right-to-Die:
Laws against Causing Premature Death

Losing the Marks of Personhood:
Discussing Degrees of Mental Decline

Advance Directives for Medical Care:
24 Important Questions to Answer

Fifteen Safeguards for Life-Ending Decisions

Will this Death be an "Irrational Suicide" or a "Voluntary Death"?

Will this Death be a "Mercy-Killing" or a "Merciful Death"?

Four Medical Methods of Managing Dying

Methods of Managing Dying in a Right-to-Die Hospice

Why Giving Up Water is Better than other Means of Voluntary Death

Voluntary Death by Dehydration:
Safeguards to Make Sure it is a Wise Choice

The One-Month-Less Club:
Live Well Now, Omit the Last Month

Choosing Your Date of Death:
How to Achieve a Timely Death
—Not too Soon, Not too Late

The Living Cadaver:
Medical Uses of Brain-Dead Bodies

Don't Kill Yourself!

Further Reading:

Best Books on Terminal Care (from the Doctor's Point of View)

Books on Hospice Care

Terminal Medical Care from the Consumer's Point of View

Books on Advance Directives for Medical Care

Best Books on Voluntary Death

Best Books on Preparing for Death

Books on Terminal Care

Medical Methods of Managing Dying

Books on Helping Patients to Die

Books Supporting the Right-to-Die

Books Opposing the Right-to-Die

Go to the Right-to-Die Portal.

Go to the Book Review Index
to discover 350 reviews
organized into 60 bibliographies.

Return to the DEATH page.

Go to the Medical Ethics index page.

Go to other on-line essays by James Park,
organized into 10 subject-areas.

Go to the beginning of this website
James Leonard Park—Free Library


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